Mandatory Immunization

Health History Form

GENERAL EDUCATION

Section A: Required Immunizations Information

*Please note: All titers must include a lab report*
Basic Instructions:
1. MMR / MEASLES, MUMPS, RUBELLA VACCINE:  DO NOT WAIT! Review your
Required for everyone born after Dec. 31, 1956. Two doses are required. You must have Student Self-Service Portal and
received on or after 12 months of age AND in 1971 or later. The second dose must have submit missing documents at least
been received at least 30 days after the first dose AND in 1990 later. OR Provide lab three (3) weeks prior to orientation
evidence of immunity by doing a blood test to check for antibodies for Measles, Mumps and or registration.
Rubella. If you do a blood test, you need to provide the results on a lab form that should be
faxed or mailed with the completed Mandatory Immunization Health History Form.
 Include the student’s UFID on all
correspondence. Print all student
2. HEPATITIS B VACCINE:
information legibly (name, phone,
Students are required to receive this vaccination OR read the CDC’s Vaccine Information
Statement and sign where indicated on the Form to decline. Read the VIS here: etc.).
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html. Signing the waiver
indicates you understand the possible risk in not receiving this vaccine. If you are under the  MINORS (students under 18):
age of 18 and wish to decline this vaccine, a parent must sign for you. Include a signed copy of the Minor
Medical Treatment Consent Form
3. MCV4 (MENACTRA/MENVEO) / MENINGOCOCCAL MENINGITIS VACCINE:
Students are required to receive this vaccination OR read the CDC’s Vaccine Information  Keep a copy for your records.
Statement and sign where indicated on the Form to decline. Read the VIS here:
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.html. Signing the waiver  Enter vaccine dates and upload
indicates you understand the possible risk in not receiving this vaccine. If you are under 18 form through Student Self-Service
and wish to decline this vaccine, a parent must sign for you. Portal

4. TUBERCULOSIS SCREENING:  Check UF account to see if the

Required for International Students. History of BCG vaccination does not satisfy the TB immunization checklist has been
screening requirement. Must have completing testing within the 12 months prior to starting cleared: one.uf.edu. Health
classes. If either screening is returned positive, then you must get a chest x-ray and submit a Compliance does not send
copy of the report. confirmation that an individual form
 FOR TST (Mantoux): The result of the TST needs to be recorded in mm in the space has been received.
provided on the form and whether considered negative or positive.
 For Interferon-based Assay, IGRA, (QFT or T-SPOT): You must submit a copy of the
lab report. Contact Us:

Section B: Optional Immunizations – Not Required for Matriculation UF Health Compliance Office

 COVID-19: Email: healthcompliance@shcc.ufl.edu

The mRNA COVID-19 vaccine series consist of two doses administered intramuscularly. Phone: 352-294-2925
Both doses of the series should be completed with the same product and in the time Fax: 352-392-0938
intervals specified by the manufacturer. Mail: P.O. Box 117500 Gainesville, FL
32601-7500
 Td (Tetanus/Diphtheria) or/and Tdap (Tetanus/Diphtheria/Pertussis):
Tdap = Adacel/Boostrix. Booster shot within last 10 years.

 Varicella (Chickenpox): **Please note: Email sent over the Internet

Provide proof of two doses of Varivax OR provide results of a blood test on a lab form is not necessarily secure. Please be aware
verifying immunity to Chickenpox/Varicella. Please note that all titers must include that the University of Florida (UF) Health
the lab report. Compliance Office and the UF Student Health
Care Center (SHCC) cannot guarantee the
 Hepatitis A, HPV, Polio: confidentiality or security of any information
In this section you may also list any additional vaccines that were administered. sent over the Internet when using email. UF
and/or the SHCC shall not be liable for any
 Meningitis B: breach of confidentiality resulting from such
Please specify whether Bexsero (2 doses) or Trumenba (3 doses) in the space provided. use of email via the Internet.
View the CDC VIS at cdc.gov/vaccines/hcp/vis/vis-statements/mening-serogroup.html.
 OFFICE USE ONLY General Education
MRN:________________________ Immunization Form
REQUIRED – UFID NUMBER (8 digits):

 -
Name: _________________________________________ First Term of Attendance:  FALL  SPRING  SUMMER

Date of Birth: ____________________________________ Phone: _____________________________________

SECTION A: Required Immunizations

Vaccine Name Date Date Date Titer Date & Result
(MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (Must include lab report)

1. MMR (Measles, Mumps, Rubella) --NOT APPLICABLE--

(2 doses after 12 months of age)

2. Hepatitis B

 I have read the information about Hepatitis B and decline receipt of this vaccine.
____________________________________________________________________________ _____________________
Student or Guardian Signature Date
3. MCV4 (Menactra/Menveo)
--NOT APPLICABLE--
(must be from 2005 or later)
 I have read the information about MCV4 (Menactra/Menveo) / Meningococcal Meningitis and decline receipt of this vaccine.
____________________________________________________________________________ _____________________
Student or Guardian Signature Date

4. Tuberculosis Screening (Required for International Students) Must be completed within the 12 months prior to start of classes.
Date Placed Date Read MM
TB Skin Test by TST (Mantoux) Result: Neg Pos
Date Result
OR Interferon-based Assay (QFT or T-SPOT) Submit copy of lab report in English

Date Result
Chest X-ray (Only if positive TST or Lab Test) Submit copy of x-ray report in English

SECTION B: Optional Immunizations

Td --NOT APPLICABLE--
Tdap (Adacel/Boostrix) --NOT APPLICABLE--

Varicella (Chickenpox) --NOT APPLICABLE--

Hepatitis A
HPV (Gardasil or Cervarix) --NOT APPLICABLE--

Moderna
COVID-19 Pfizer
J&J
Bexsero --NOT APPLICABLE--
Meningitis B
Trumenba --NOT APPLICABLE--

An official stamp from a doctor’s office, clinic or health department AND an authorized signature must appear here or this form will not be approved.

___________________________________________________________ _________________________________________ ______________________________

Official Office Stamp Here Physician or Authorized Signature Date